Computer-Assisted Access to Specialist Expertise

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Cleveland,
Ohio44106

Purpose:

The goal of this research was to determine if providing specialist input to primary care
providers (PCPs) by means of informal consultation could improve the process and outcomes of
care for diabetes. Several studies support the role for specialists and their specific
knowledge and expertise in a variety of disorders including diabetes. A variety of methods
have been designed to optimize the use of specialty expertise including practice guidelines
and disease management approaches as well as the consultation/referral process. The
referral-consultation process is an important mechanism for obtaining clinically useful
information. At one end of the spectrum of this process, informal consultation involves
discussion about a patient with a colleague without the consultant seeing the patient; at
the other end of the spectrum, care of the patient is transferred to another physician and
the process is formalized. Because much specialist expertise resides in the specialists
themselves, the expansion of primary care sites to include community-based outpatient
clinics has implications for access to the specialists located elsewhere. This study was
designed to evaluate a computer-assisted voice mail system which is relatively inexpensive
and more convenient than video-telemedicine systems, making it more practical and more
easily exportable. Diabetes care delivery was chosen as the model in which to assess
informal consultation based on its frequency among veterans, management challenges, and the
emphasis on improvement in diabetes care in VA. A secondary goal of the project was to
better characterize the consultation process.

Study summary:

Background:
The goal of this research was to determine if providing specialist input to primary care
providers (PCPs) by means of informal consultation could improve the process and outcomes of
care for diabetes. Several studies support the role for specialists and their specific
knowledge and expertise in a variety of disorders including diabetes. A variety of methods
have been designed to optimize the use of specialty expertise including practice guidelines
and disease management approaches as well as the consultation/referral process. The
referral-consultation process is an important mechanism for obtaining clinically useful
information. At one end of the spectrum of this process, informal consultation involves
discussion about a patient with a colleague without the consultant seeing the patient; at
the other end of the spectrum, care of the patient is transferred to another physician and
the process is formalized. Because much specialist expertise resides in the specialists
themselves, the expansion of primary care sites to include community-based outpatient
clinics has implications for access to the specialists located elsewhere. This study was
designed to evaluate a computer-assisted voice mail system which is relatively inexpensive
and more convenient than video-telemedicine systems, making it more practical and more
easily exportable. Diabetes care delivery was chosen as the model in which to assess
informal consultation based on its frequency among veterans, management challenges, and the
emphasis on improvement in diabetes care in VA. A secondary goal of the project was to
better characterize the consultation process.
Objectives:
Patients with diabetes mellitus are complex and may benefit from the input of multiple
specialists and PCPs must determine the need for and coordinate the input from those
multiple specialists. With that in mind, the three objectives of the study are: 1) To assess
the impact of computer-assisted access to specialist expertise (CASE) on process of care for
patients with diabetes mellitus; 2) To assess the impact of CASE on outcomes of care at the
patient level (clinical outcomes and satisfaction), provider level (satisfaction) and the
system level (health services utilization and costs); and 3) To characterize the
consultation-referral process in community-based outpatient clinics (CBOCs).
Methods:
Randomized controlled trial with access to the CASE system constituting the intervention and
a descriptive study of the consultation process. The major outcome variables will be the
consultation type, adherence to diabetes practice guidelines, clinical outcome of diabetes
care (glycemic control), patient and provider satisfaction.
Status:
Project work has been completed. The final report has been submitted.